Introduction: Gallstone disease is a leading gastrointestinal cause for hospitalizations. Complicated gallstone disease encompasses gallstone-related complications which include acute cholangitis, acute cholecystitis, acute pancreatitis, gallstone ileus and Mirizzi syndrome.

Case Presentation: We present a 82 year-old male with history of HTN, NAFLD, GERD, hypothyroidism, status post cholecystectomy who presented with BP 145/69, HR 74, T 99.5F, severe epigastric abdominal pain radiating to the back, 8/10 in intensity, profound jaundice, nausea, and vomiting. He was diagnosed, at another facility, with a 1 cm calculus in the common hepatic duct and 3 and 8 mm calculi in the distal common bile duct in tandem configuration 3 weeks ago and was referred for outpatient GI consultation for which he had bene waiting until this admission. At his previous admission labs showed: total bilirubin 8.7, AST 169, ALT 172, ALP 398, lipase normal. Labs on admission showed: WBC 11K, K 2.9, total bilirubin 15.20, AST 402, ALT 256, ALP 758, lipase > 40,000.

Final Diagnosis: Patient was diagnosed with obstructive jaundice secondary to complicated choledocholithiasis with acute cholangitis and acute biliary pancreatitis, was started on IVF and Zosyn, and he underwent ERCP.

Management: ERCP revealed multiple stones, with at least 3 of them very large, in the distal common bile duct as well as a dilated cystic duct. All 3 stones were successfully extracted. Given the size of the stones, sphincterotomy was performed. Post ERCP lipase down trended to 265; total bilirubin decreased to 6, AST and ALT decreased to 84 and 96 respectively, ALP decreased to 351. Patient was successfully discharged home.

Conclusion: This case report highlights the importance of early diagnosis and timely management of gallstone disease. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence.